Premature sebaceous gland hyperplasia* R i c h a r d L. De Villez, M.D., and Larry C. Roberts, Captain, MC, USAF San Antonio, TX A case of premature sebaceous gland hyperplasia of the face in a young man is described. The clinical and histologic differentiation from other papulonodular facial lesions is discussed. (J A ~ ACAO DERMA.TOL 6:933-935, 1982.)
T h e occurrence of senile sebaceous hyperplasia, particularly in m e n past middle age, is a well-documented and frequently observed clinical condition. 1 It presents as several to many elevated, soft, yellowish papules or nodules with central umbilication on the face, particularly the forehead. We describe in this report a patient who developed extensive sebaceous hyperplasia of the face at puberty, and to our knowledge this has not been d o c u m e n t e d previously. CASE REPORT
A 29-year-old Latin American man presented to the Robert B. Green Dermatology Clinic complaining of "pits and lumps" on his face that developed at the age of 12 when he reached puberty. He further complained of very oily skin that was a constant source of social embarrassment. He had been treated unsuccessfully with both systemic and topical ache medications. At the age of 12 he experienced head trauma and subsequently developed a seizure disorder which was controlled with phenobarbital. There was no family history of a similar skin problem. No evidence for precocious puberty could be elicited. Physical examination revealed a young man with a broad nose, moderately bushy eyebrows, and thick lips. There were numerous 1- to 2-mm yellow, wellcircumscribed papules with central umbilication on the
From the Division of Dermatology, University of Texas Health Scie n c e Center at San Antonio. Reprints not available. *The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Air Force or the Department of Defense.
nose, cheeks, forehead, and chin from which sebum was easily expressed (Fig. 1). An occasional erythematous, acneiform papule or pustule was present on the cheeks and chin. No facial erythema, telangiectasia, or rhinophyma was noted. No abnormalities of the genital organs or sexual hair pattern were noted. A shave biopsy from the right side of the nose revealed sebaceous gland hypertrophy with a minimal scattered lymphohistiocytic infiltrate and no telangiectasia. Both cellular and glandular maturation was normal. At a later date, a 2-mm punch biopsy of a papule on the right cheek showed a similar histologic picture (Fig. 2). The patient was treated intensively with benzoyl peroxide, topical retinoic acid, astringent cleanser, minocycline, and tetracycline over the course of several months but failed to show diminution in either the number of papules or the oiliness of his skin. DISCUSSION Senile sebaceous hyperplasia is described as a benign condition occurring in people over the age of 40. The youngest reported case, to our knowledge, was diagnosed in a 50-year-old man who recalled squeezing a lesion on his forehead at 18 years o f a g e ) Our patient represents an unusual manifestation of this condition with the onset at puberty. Sebaceous hyperplasia in this patient was differentiated from early rhinophyma by the diffuse distribution of the sebaceous glands on the face and the lack of hypertrophy of the nose. Although initially considered, a diagnosis of rosacea could not be made clinically in the absence of erythema and telangiectasia. Furthermore, the biopsies revealed sebaceous hyperplasia without follicular 933
De Vil[ez and Roberts
Journal of the American Academyof Dermatology
Fig. 1. Multiple papules with minimal inflammation are seen on the cheeks (A) and chin (B). occlusion, telangiectasia, significant perivascular inflammatory infiltrate, or epithelioid cell tubercles typicaIly seen in rosacea, a Fordyce's condition is sebaceous hyperplasia on the vermilion border of the lips, the incidence of which increases with age. Histologically the sebaceous glands are small with mature sebaceous lobules and small s e b a c e o u s d u c t s . 4 Multiple sebaceous adenomas may present solitary or multiple yellow papules on the face that are virtually indistinguishable from sebaceous hyperplasia. However, microscopic examination would reveal irregularly sized lobules and undifferentiated germinative cells at the periphery of the sebaceous glands.5 Multiple trichoepithelioma is a dominantly inherited condition that presents at adolescence, and the lesions gradually enlarge in size and number. Multiple round, skin-colored, firm nodules without central umbilication between 2 and 8 mm in size are found on the face, scalp, and occasionally on the trunk. Immature hair structures are characteristic on histologic study. ~ Patients with tuberous sclerosis frequently demonstrate multiple facial papules symmetrically distributed in the nasolabial folds and on the cheeks and chin. These are, in actuality, angiofibromas, and the sebaceous glands are often atrophic, r Multiple follicular fibromas are seen on the face, as well as on the back and arms, where they appear as "gooseflesh."8 Histologically sebaceous hypeFplasia must be differentiated from nevus sebaceus, sebaceous adenoma, basal cell epithelioma with sebaceous dif-
ferentiation, and sebaceous carcinoma. Nevus sebaceus may contain hyperplastic sebaceous glands, but it is also accompanied by papillomatosis, immaturity or absence of hair follicles, dilated apocrine glands, and the presence of various benign and malignant tumors. 9 Sebaceous adenomas have an organoid pattern less perfect than the normal sebaceous gland, and the normal maturation of the cells fi'om germinative layer at the periphery to complete differentiation centrally is impaired. The peripheral germinative cell layer is several cells thick in contrast to the one-cell thick layer of normal sebaceous gland, t0 The basal cell epitheliomas with sebaceous differentiation demonstrate irregular cellular masses lacking the orderly architecture of normal sebaceous glands. Immature or germinative sebaceous cells outnumber the mature sebaceous cells. Microcysts containing keratin are frequent, t° Finally, sebaceous carcinomas, including those originating from meibomian glands, reveal irregular lobular formations with marked variation in size, many undifferentiated cells, and atypical sebaceous cells with significant nuclear pleomorphism, mitotic figures, and atypical keratinization.l° We feel that this patient had premature sebaceous gland hyperplasia symmetrically distributed over the face and appearing at puberty. The lesions were easily differentiated histologically from other sebaceous neoplasms and clinically from the many causes of facial papules and nodules by their distribution and morphologic features.
Volume 6 Number 5 May, 1982
Sebaceous gland hypelpIasia 935
Fig. 2, A, Punch biopsy of hyperplastic sebaceous gland. (Hematoxylin-eosin stain; original magnification, x 25 .) B, The same gland showing normal maturation and architecture. (Hematoxylin-eosin stain; original magnification, × 4 0 0 . )
REFERENCES i. Nomland R: Senile sebaceous adenoma. Arch Dermatol Syphilol 22:1004-1009, 1930. 2. Gilman RL: Adenomatoid sebaceous tumors, with particular reference to adenomatoid hyperplasia. Arch Dermatol Syphilol 35:635-642, 1937. 3. Ackerman AB: Histologic diagnosis of inflammatory skin diseases. Philadelphia, 1978, Lea & Febiger, p. 658. 4. Miles AEW: Sebaceous glands in the lip and cheek mucosa of man. Br Dent J 105:235-248, 1958. 5. Mehregan AH, Homayoon R: Benign epithelial tumors of the skin. II. Benign sebaceous tumors. Cutis 19:317320, 1977.
6. Mehregan AH, Pinkus H: Adnexal tumors of the skin. Int J Dermatol 10:61-78, 1971. 7. Okun MR, Edelstein LM: Gross and microscopic pathology of the skin. Boston, 1976, Dermatopathology Foundation Press, p. 206. 8. Zackheim HS, Pinkus H: Perifollicular fibromas. Arch Dermatol 82:913-917, 1960. 9. Lever WF, Schaumburg-Lever G: Histopathology of the skin. Philadelphia, 1975, J. B. Lippincott Co, pp. 501502. 10. Rulon DB, Helwig EB: Cutaneous sebaceous neoplasms. Cancer 33:82-102, t974.